Provider Demographics
NPI:1124566179
Name:FOWLER, DESAREE (PNP-PC)
Entity Type:Individual
Prefix:
First Name:DESAREE
Middle Name:
Last Name:FOWLER
Suffix:
Gender:F
Credentials:PNP-PC
Other - Prefix:
Other - First Name:DESAREE
Other - Middle Name:
Other - Last Name:FOWLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN. CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:672 W 400 S STE 101
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-3170
Practice Address - Country:US
Practice Address - Phone:801-491-9883
Practice Address - Fax:801-489-3141
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-03137363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics